Lung Cancer

Lung Cancer

Lung cancer is one of the most common cancers in India. This has been linked to multiple carcinogens and is mostly associated with smoking, both passive and active Surgery, radiation & chemotherapy are the three modalities commonly used to manage the disease in patients.



Overview of Lung Cancer

There are many types of lung cancers. Lung Cancer is caused by lung cells growing out of control. As the number of cells grow, they form into a tumor. Globally, the incidence of lung cancer is more in men over women, associated with the higher number of men who smoke as compared to the latter

Staging of NSCLC patients is critical as it plays an important role in the therapeutic decision making process.

  • Resection, including wedge resection, is the preferred treatment modality for early stage localized NSCLC
  • Chemotherapy plays a major role, either alone or in combination with other modalities
  • Given the stage of detection of the disease, a few patients also seek palliative care as well

Risk Factors

Both exposure (environmental or occupational) to particular agents & an individual’s susceptibility to these agents are thought to contribute to one’s risk of developing lung cancer

Risk Factors
Tobacco Usage - Smoking of cigarette & Beedi constitute a significant reason for lung cancer
Asbestos Exposure
Radon/Halogen Exposure
Inorganic arsenic Exposure
Atmospheric pollution
Exposure to heavy minerals - e.g. Chromium, nickel exposure
Vinyl Chloride exposure

Symptoms

The following are the common symptoms of lung cancer

Common Symptoms
Cough that does not go away
Wheezing (breathe with a whistling or rattling sound in the chest)
Weight loss without any explanation
Loss of appetite
Trouble breathing
Blood in urine
Streaks of blood in sputum/cough
Chest discomfort
Tiredness
Hoarseness
Significant pain in the body without any explanation

Diagnosis

Imaging tools are used to understand the spread , extent and confirm cancer. However, they are not sufficient to confirm malignancy of the disease as both benign and malignant tumors exhibit same behaviour on radiographs.

Hence it is typical for an imaging test to be followed by tests for histological confirmation. Additionally, biomarker tests and biopsy procedures are done to stage the disease/confirm the disease

Common Imaging tests include

  • X Ray
  • CT Scan
  • PET Scan
  • MRI Scan
  • Bone Scans

Treatment Options

A significant percentage of patients with NSCLC are diagnosed at an advanced stage, for which 5-year survival rate is not very high. However, with newer drugs being available, the situation is changing for the better and we are seeing progress in the survival rate among patients

Once the patient is diagnosed with the disease, Surgery, radiation therapy (RT) and chemotherapy are the three modalities commonly used to treat patients with NSCLC

Staging of NSCLC patients is critical as it plays an important role in the therapeutic decision making process. This must be done correctly by consulting with the healthcare provider as this decides the goal and the outcome of the treatment.

No two patients may get the same treatment, however typical treatment for lung cancer includes

Approach Description
Surgery Surgery is done on the tumor to treat lung cancer - as a part of this all or a part of the lung is removed.
  • Surgery remains the mainstay of all patients with stage I and II lung cancer. The surgery may consist of pneumonectomy, lobectomy, or segmentectomy ,depending on the history of the patient, where all or part of the lung is removed. In some cases, the surgeon may remove nearby lymph nodes as well.
  • Surgery is often accompanied by radiation therapy and/or systemic therapy.
Systemic therapy(Chemotherapy) Chemotherapy is a systemic therapy that uses anti-cancer drugs to kill or stop the growth of cancer cells
  • Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). Most types of chemotherapy used for lung cancer are given by IV injection.
  • Common examples include: Carboplatin (Paraplatin) or cisplatin (Platinol), Docetaxel (Docefrez, Taxotere, Gemcitabine (Gemzar), Nab-paclitaxel (Abraxane), Paclitaxel (Taxol), Pemetrexed (Alimta), Vinorelbine (Navelbine)
Systemic therapy(Targeted Therapy)

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

  • Avastin and Cyramza are used for starving the tumor of nutrients by stopping angiogenesis, which the process of making new blood vessels
  • Patients who are positive for the "EGFR" biomarker can be treated with drugs like Erlotinib (Tarceva) , Gefitinib (Iressa) and Afatinib (Gilotrif)
  • Patients who test positive for the "ALK" biomarker can be treated with drugs like crizotenib, alectenib
Systemic therapy(Immunotherapy)

These are the latest drugs against cancer and are not yet commercially available in India. Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. For example, the PD-1 pathway may be critical in the immune system’s ability to control cancer growth. Blocking this pathway with PD-1 and PD-L1 antibodies has stopped or slowed the growth of NSCLC for some patients.


The following drugs block this pathway:

  • atezolizumab
  • nivolumab
  • pembrolizumab
External Radiotherapy External beam is a treatment option that uses localized high energy radiation beams to eliminate cancer cells and keep them from growing.
  • Radiation therapy (i.e using powerful x-rays or other radition forms to kill cancer cells) can be used for
    • Primary local treatment for patients with medically inoperable or unresectable NSCLC
    • Adjuvant therapy for resectable NSCLC patient with no contraindication for surgery
    • Palliative therapy for patients with incurable NSCLC
    • It is important to note that the post surgery, lung tolerance to radiation therapy is much less than intact lungs. Patients should discuss with the treating doctor on associated side-effects
    Brachytherapy Brachytherapy uses a radioactive substance, usually in the form of seeds which are placed directly into or near the cancer which helps to shrink the tumor.

    Treatment Options

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